Every finding on record at Lenity Home Care LLC

The following reflects the findings of the California Department of Public Health during the Complaint Validation Survey conducted from 1/6/25 to 1/9/25. During the survey following COP (condition of participation)s were reviewed. 484.45 Reporting Oasis Information 484.50 Patient Rights 484.1 Basis and Scope 484.100 Compliance with Federal, State , Local law 484.105 Organization and Administration of Services The agency found to be out of compliance with CFR (code of federal regulation) 484.100 Compliance with Federal, State , Local law and CFR 484.1 Basis and Scope.

Basis and Scope CFR(s): §484.1 Basis and Scope (a) Basis. This part is based on: (1) Sections 1861(o) and 1891 of the Act, which establish the conditions that an HHA must meet in order to participate in the Medicare program and which, along with the additional requirements set forth in this part, are considered necessary to ensure the health and safety of patients; and (2) Section 1861(z) of the Act, which specifies the institutional planning standards that HHAs must meet. (b) Scope. The provisions of this part serve as the basis for survey activities for the purpose of determining whether an agency meets the requirements for participation in the Medicare program. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the agency failed to establish the conditions that an HHA must meet in order to participate in the Medicare program when the agency knowingly provide services in a new location and county without first completing CMS (center for Medicare and Medicaid Services) application form. This failure resulted in providing home health care services in a location the facility was not approved to provide services starting on 8/3/23 and potentially could negatively affect the care of all patients. The cumulative effect of these systemic problems resulted in the agency’s inability to provide care in a safe and quality setting. During a concurrent observation and interview, on 1/6/25 at 1:30 p.m., with the Administrator/Direct Patient Care Services (Adm/DPCS), at the agency located in 4950 E. Yale Ave Fresno, the State License was observed displaying the following information. “State of California Department of Public Health…this License to [agency] 315 W Oak Avenue Visalia, CA 93291-4928...effective: 08/05/2024 expires: 08/04/2025…” The Adm/DPCS was asked to explain the reason for not having current address on the license displayed in the lobby. The Adm/DPCS stated the agency relocated from Visalia to Fresno on 10/1/23 (more than a year ago). The Adm/DPCS stated “I have received the letter from CAB (Central Applications Branch - the unit of CDPH that reviews and processes Change of Location applications) on 9/20/24 and submitted the required doc (documents) on 10/1/24. Sacramento called me on 12/24/24 stating she wanted more information about change of address. She validated change of address and she said everything was fine.” During a concurrent interview and record review, on 1/6/25 at 2:10 p.m., with the Adm/DPCS, the letter from CAB titled “Application Deemed Incomplete” dated September 20, 2024, addressed to the previous administrator (Adm 1) 315 W Oak Avenue, Visalia, CA 93291, was reviewed. When the letter was presented to Adm/DPCS, the Adm/DPCS stated the letter was sent out to the previous administrator and previous address and she did not receive it. he ADM/DPCS was asked to provide proof of Report of Change (ROC) to update the Administrator, and any notification of approval. The Adm/DPCS stated she did not report the change of Administrator that occurred in April 2024, but that Adm 1 had reported the change of location In August 2023. During an interview on 1/6/25 at 3:00 p.m., with the Adm/DPCS, the Adm/DPCS stated the reason for the agency moved from Visalia to Fresno was to manage business in one location along with the Hospice and In-Home care in Fresno since the HHA in Visalia was not busy. The Adm/DPCS stated the HHA in Fresno currently had 20 active patients. The Adm/DPCS stated the current Fresno location had been not busy as well and she was planning to move the agency to a smaller place. During an interview on 1/6/25 at 3:30 p.m., with the Designated Administrator (DA), the DA stated she was the one who submitted the application for CHOL The DA stated she thought if she reported the changes to the State within 30 days, the agency followed the law. The DA stated she did not know the agency required approval prior to move. During a phone interview on 1/6/25 at 3:40 p.m. with Adm 1, Adm 1 stated that as of April 2024 he was no longer the administrator, and all the correspondence should have gone to the Adm/DPCS. Adm 1 stated he knew the CHOL process and that a licensing survey needed to be completed upon approval of the application. The Adm 1 stated the agency moved to the current location on 8/3/23 and the ROC was filed on 8/6/23. Adm 1 stated he reported to CMS (Center for Medicare and Medicaid Services) and filed 855A (Medicare Enrollment application) on 8/21/23. Adm 1 stated he did not know the application was incomplete. Adm 1 stated he changed Email contact to Adm/DPCS on March 2024 when he was no longer the Administrator of the HHA (Home Health Agency). A review of the facility’s copy of the form HS 200 (a form for Licensure & Certification Application) dated 8/6/23, contained the agency’s letterhead titled “Change of Location and Mailing Address.” The packet included the priority mail receipt indicating the package was shipped to CAB on 8/23/23. A review of the agency’s CHOL application packet contained the document titled “Commercial Lease Agreement”. The lease agreement, dated and signed on 7/26/23, indicated the term begins on September 1, 2023. A review of the agency’s Email inquiry titled “CDPH (California Department of Public Health) Internet Admin Inquiries” indicated the provider emailed CAB on 6/28/24 inquiring the status of the CHOL application submitted on 8/16/23. The CAB replied to the provider on 7/2/24, indicating that they received the application on 2/22/24 and it was currently pending assignment to an analyst. A review of letter from CAB titled “Application Deemed Incomplete” dated 9/20/24, contained the list of missing information from the provider and the instructions to complete the application. During a review of faxed document titled “Application Pending Regional Office Review Medicare Application” dated 8/21/23, indicated, “Your current Medicare application in PECOS. Status Approval Pending Regional Office Approval.” During a review of “Certificate of Accreditation from ACHC” posted in the agency’s lobby, the certificate indicated, “[the agency] Home Health Accreditation #77779 Visalia California From November 12, 2022, through November 12, 2025.” During an interview on 1/9/25 at 2:00 p.m., with the Adm/DPCS, at the agency, the Adm/DPCS stated she knew she had been providing home health services for over one year without approved state license reflecting current address. The Adm/DPCS also stated she could not provide any evidence that the agency informed the deeming agency /CMS for CHOL. The Adm/DPCS acknowledged she violated state law and Health and Safety Code by not responding to the correspondence and by not following up on the status of the CHOL for an extended period time. During a review of patient listing on the date of move on 8/3/23 contained 22 patients. During a review of patients listing for discharged patients from 8/3/23 (moving date) to 9/6/24 (survey entrance date) contained 122 patients. During a review of active patient listing on 1/6/24 (survey entrance date) contained 20 patients. A review of the agency’s job description titled “Executive Director/Administrator” dated 12/18, indicated, “Complying with applicable law and regulation…Ensuring the accuracy of public information materials and activities…”

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the agency failed to follow federal and state laws and regulations related to submission of a complete Change of Location (CHOL) for their licensed agency The Home Health Agency changed location and county without first submitting a complete application for review and approval. The agency failed to follow federal rules to submit a CHOL application prior to relocating. These failures resulted in providing home health care services in a location the facility was not approved to provide services starting on 8/3/23 and potentially could negatively affect the care of all patients. The cumulative effect of these systemic problems resulted in the agency’s inability to provide care in a safe and quality setting. During a concurrent observation and interview, on 1/6/25 at 1:30 p.m., with the Administrator/Direct Patient Care Services (Adm/DPCS), at the agency located in 4950 E. Yale Ave Fresno, the State License was observed displaying the following information. “State of California Department of Public Health…this License to [agency] 315 W Oak Avenue Visalia, CA 93291-4928...effective: 08/05/2024 expires: 08/04/2025…” The Adm/DPCS was asked to explain the reason for not having current address on the license displayed in the lobby. The Adm/DPCS stated the agency relocated from Visalia to Fresno on 10/1/23 (more than a year ago). The Adm/DPCS stated “I have received the letter from CAB (Central Applications Branch - the unit of CDPH that reviews and processes Change of Location applications) on 9/20/24 and submitted the required doc (documents) on 10/1/24. Sacramento called me on 12/24/24 stating she wanted more information about change of address. She validated change of address and she said everything was fine.” During a concurrent interview and record review, on 1/6/25 at 2:10 p.m., with the Adm/DPCS, the letter from CAB titled “Application Deemed Incomplete” dated September 20, 2024, addressed to the previous administrator (Adm 1) 315 W Oak Avenue, Visalia, CA 93291, was reviewed. When the letter was presented to Adm/DPCS, the Adm/DPCS stated the letter was sent out to the previous administrator and previous address and she did not receive it. he ADM/DPCS was asked to provide proof of Report of Change (ROC) to update the Administrator, and any notification of approval. The Adm/DPCS stated she did not report the change of Administrator that occurred in April 2024, but that Adm 1 had reported the change of location In August 2023. During an interview on 1/6/25 at 3:00 p.m., with the Adm/DPCS, the Adm/DPCS stated the reason for the agency moved from Visalia to Fresno was to manage business in one location along with the Hospice and In-Home care in Fresno since the HHA in Visalia was not busy. The Adm/DPCS stated the HHA in Fresno currently had 20 active patients. The Adm/DPCS stated the current Fresno location had been not busy as well and she was planning to move the agency to a smaller place. During an interview on 1/6/25 at 3:30 p.m., with the Designated Administrator (DA), the DA stated she was the one who submitted the application for CHOL The DA stated she thought if she reported the changes to the State within 30 days, the agency followed the law. The DA stated she did not know the agency required approval prior to move. During a phone interview on 1/6/25 at 3:40 p.m. with Adm 1, Adm 1 stated that as of April 2024 he was no longer the administrator, and all the correspondence should have gone to the Adm/DPCS. Adm 1 stated he knew the CHOL process and that a licensing survey needed to be completed upon approval of the application. The Adm 1 stated the agency moved to the current location on 8/3/23 and the ROC was filed on 8/6/23. Adm 1 stated he reported to CMS (Center for Medicare and Medicaid Services) and filed 855A (Medicare Enrollment application) on 8/21/23. Adm 1 stated he did not know the application was incomplete. Adm 1 stated he changed Email contact to Adm/DPCS on March 2024 when he was no longer the Administrator of the HHA (Home Health Agency). A review of the facility’s copy of the form HS 200 (a form for Licensure & Certification Application) dated 8/6/23, contained the agency’s letterhead titled “Change of Location and Mailing Address.” The packet included the priority mail receipt indicating the package was shipped to CAB on 8/23/23. A review of the agency’s CHOL application packet contained the document titled “Commercial Lease Agreement”. The lease agreement, dated and signed on 7/26/23, indicated the term begins on September 1, 2023. A review of the agency’s Email inquiry titled “CDPH (California Department of Public Health) Internet Admin Inquiries” indicated the provider emailed CAB on 6/28/24 inquiring the status of the CHOL application submitted on 8/16/23. The CAB replied to the provider on 7/2/24, indicating that they received the application on 2/22/24 and it was currently pending assignment to an analyst. A review of letter from CAB titled “Application Deemed Incomplete” dated 9/20/24, contained the list of missing information from the provider and the instructions to complete the application. During a review of faxed document titled “Application Pending Regional Office Review Medicare Application” dated 8/21/23, indicated, “Your current Medicare application in PECOS. Status Approval Pending Regional Office Approval.” During a review of “Certificate of Accreditation from ACHC” posted in the agency’s lobby, the certificate indicated, “[the agency] Home Health Accreditation #77779 Visalia California From November 12, 2022, through November 12, 2025.” During an interview on 1/9/25 at 2:00 p.m., with the Adm/DPCS, at the agency, the Adm/DPCS stated she knew she had been providing home health services for over one year without approved state license reflecting current address. The Adm/DPCS also stated she could not provide any evidence that the agency informed the deeming agency /CMS for CHOL. The Adm/DPCS acknowledged she violated state law and Health and Safety Code by not responding to the correspondence and by not following up on the status of the CHOL for an extended period time. During a review of patient listing on the date of move on 8/3/23 contained 22 patients. During a review of patients listing for discharged patients from 8/3/23 (moving date) to 9/6/24 (survey entrance date) contained 122 patients. During a review of active patient listing on 1/6/24 (survey entrance date) contained 20 patients. A review of the agency’s job description titled “Executive Director/Administrator” dated 12/18, indicated, “Complying with applicable law and regulation…Ensuring the accuracy of public information materials and activities…”